Profile

Account information

Password*

Confirm password*

Personal Information

First name

Middle name

Last name

Alternate Names

Gender

Date of Birth

Place of Birth

Contact Information

Address

Address (cont.)

City

Country

State

Postal Code

Primary Phone Number

Secondary Phone Number

Citizenship

Are you a US citizen?

Yes No

If you are not a US citizen, which of the following best describes your immigration status?

A qualified alien (8 U.S.C.A. 1641)

A nonimmigrant under the Immigration and Nationality Act (8 U.S.C.A. 1101)

An alien paroled into the US for less than one year (8 U.S.C.A. 1182 (D) (5))

A foreign national not physically present in the US

Other: Please provide a detailed, written explanation with supporting documentation to the jurisdiction in which you are applying for licensure.

Work History

Do you have work experience?

Yes No

If yes, please fill out all of the fields below.

Company

Position

Supervisor Name

Address

Address (cont.)

City

State

Postal Code

Company Phone

Start Date

End Date

Employment Type

Full time Part time

Hours Per Week

No. of Staff Supervised

Additional Work History Add

High School Education

Are you a high school graduate?

Yes No

High School Name

City

State

Graduation Type

Diploma GED

Date Graduated or Received GED

Post Secondary Education

Did you attend a NAB-accredited education program?

Yes No

If you attended a NAB-accredited education program, please select the program you attended from the following list:

What year did you graduate from the program?

Are you a college graduate?

Yes No

If yes, then please fill out all of the information below.

College

State

Start Date

End Date

Graduation Date

Credit Hours

Major

Degree

Additional Post Secondary Education Add

Field Experience

Have you completed an AIT program and/or an internship in a facility providing long-term care?

Yes No

Number of AIT program/internship hours completed

NAB Clarus

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